New Broker Registration - Individuals - The California FAIR Plan

CA FAIR Plan Distribution Management

Individuals

"*" indicates required fields

Please complete the below with the principal/owner's information. Questions may be directed to cfpbrokers@cfpnet.com.

Individual refers to a single registered person with the California Department of Insurance, or a sole proprietor.

Only complete this form if this is your first time registering with the FAIR Plan.

Name of Broker/Individual:*

California Department of Insurance Agency License #*

Agency Owner's First and Last Name:*

First Last

Agency Owner's Office Phone #:*

Agency Owner's Cell Phone #:*

Agency Owner's Email:*

Please ensure this is the primary email address for the Agency Owner and not a distribution list.

Please fill in your complete business address below:

Street Address 1:*

Street Address 2 (for suite, apartment, or unit numbers):

City:*

State:*

ZIP Code:*

Please confirm the below:*

I have reviewed the above information to ensure it is accurate.

This field is for validation purposes and should be left unchanged.